Rabbi Sandra Katz on charting our encounters

How Can We Use Our Strengths As Documenters
to Show the Vital Role We Play on the Care Team?

Before our last National Association of Jewish Chaplains (NAJC) conference in Boca Raton, Florida, our coordinators asked me to prepare a session on documentation. This article comes from that experience.

When our long-term care facility underwent its first JCAHO inspection, it did not have a chaplain. I figured that having hired a chaplain, my facility would impress the surveyor; but the surveyor had other plans. Since then, I have worked on the subject of documentation, hoping to find a data-capturing method that is clear, concise, comprehensible, and respectful of counselees. Actually, just arriving at criteria for documentation solved a great deal of the confusion.

“If you don’t document it, you didn’t do it,” as we say in my facility. The surveyor nailed me on initial assessment. I had no explicit guidelines for what to document or how to go about it. I still chafe at the idea that I can “assess” someone. Aware of the weaknesses in my own soul, and carrying a pastoral directive that tells me to let loose of judgment, I tremble to think that I could judge another. But, the surveyor decreed that we needed to have a process by which I would attest that I had assessed each new resident. I wanted a way to indicate what I had learned about the rich lives of the people in my care.

I looked at a number of other chaplains’ assessment tools. I made numerous attempts to create a simple one-page tool for myself. Truth is, I objected to using the documents I found. Many of them assumed that the subject was Christian, and others categorized people in ways that I found to be unspiritual. I aspired to make spiritual care different, a discipline that allows people to be who they are and where they are.

In the end, I developed a set of parameters informed by Dr. Christine Puchalski’s “FICA” model. I modified Faith, Interest, Community and Address. I look at Background, Interest, Community, Pain & Loss (suggested by my boss, Reuben Schonebaum), and Approaches. I envisage something better, but at least these parameters enable a conversation that can still feel pastoral. I also had the “Pastoral Care note” formatted for my computer so that I can key in my first piece of documentation for each new resident.

In our NAJC conference session, we spoke of alternate models for documentation, especially in a hospital setting. Some facilities use peel-and-stick notes in patient charts. We heard about one facility that gave the chaplain a hand-held computer for his documentation. I ended my presentation with the notion that documentation may provide increased job security, because it points to our effectiveness and usefulness.

I hope that this article starts a wider dialogue about the process of documenting our work. How do we use criteria that open rather than close? How do we go in without an agenda when we have a form to fill? How do we make a pastoral care plan without promising something we cannot deliver? How can we use our strengths as documenters to show the vital role we play on the care team?

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